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General NPI Number Information
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NPI Number | 1407242753
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Entity Type | Organization
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Legal Business Name | CONNIE DOUGLAS LCSW
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Dates
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Enumeration Date | 04/14/2015
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Last Update Date | 04/14/2015
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Provider Practice Location Address
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Address Line | 49 MAIN ST APT 1
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City | IRVINGTON
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State | NY
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Zip | 10533-1537
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Country | US
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Telephone | 914-406-9647
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Fax |
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Provider Business Mailing Address
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Address Line | 293 BENEDICT AVE C/O THE HACKLEY SCHOOL
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City | TARRYTOWN
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State | NY
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Zip | 10591-4327
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Country | US
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Telephone | 914-406-9647
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | CONSTANCE DOUGLAS
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Credential | LCSW
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Telephone | 914-406-9647
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 071290
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License Number State | NY
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